Disability Rights Request for Assistance

Disclosures

Please note that we do not provide legal representation on the following types of cases: Criminal, employment, domestic violence, personal injury, consumer fraud, bankruptcy, evictions or foreclosures, applications or appeals for public benefits, wills/estates/trusts/conservatorships.

Completing this request for assistance form will provide us with some background information regarding your matter. After you have completed this form, it will be reviewed by an attorney. We will use our best efforts to respond to your request for assistance within four weeks of receiving the completed form. We do not guarantee that we will be able to assist you.

A submission of request for assistance form by email, phone or web does NOT establish an attorney-client relationship. An attorney-client relationship can only be established through the acceptance of the terms of and scope of representation outlined in a formal, written retainer with Disability Rights Legal Center.

You are not a client of DRLC unless you have executed a retainer with our office.

Any information that you provide is kept confidential.

In order to better direct your request for assistance, please complete the form that most directly relates to the issue you are contacting DRLC about.

Person with Disability (PWD)

If you are contacting DRLC on behalf of yourself, please fill out the information for yourself below. If you are contacting DRLC on behalf of someone else, please fill in their information below.

(If you are contacting the DRLC on behalf of someone else)

Your relationship to the PWD*

Full Name (first last) for Person with Disability*

Address (if different from above)

City*

State*

Zip code*

Language*

English

Spanish

language for person with the disability

Note: appropriate legal information and resources will be collected based on the city, county, and state of the person with disability. Please indicate if another location should be used in the memo section above.

Gender*

Male

Female

Transmale

Transfemale

Prefer not to state

Age*

Enter a number

Race/Ethnicity*

White (not Hispanic)

Hispanic/Latino

Native American

Black (not Hispanic)

Asian/Pacific Islander

Decline to State

for PWD

Monthly Household Income*

Number of People in Household*

For PWD

Does the PWD have monthly medical or other disability-related expenses?*

Yes

No

Please approximate the monthly expenses.*

Resources are often based on income level and providing accurate information will help us to provide resources that are the best match for you.

Source of Income*

Employed

Insurance

Unknown

Public Benefits

None

Other

Type of Disability*

Second Disability*

Do you give us permission to pass along your name & phone number to one of our funders for a customer satisfaction survey?*

Yes

No

Everything disclosed is confidential. Even if you give us permission to use your statistical information for research purposes, none of your personally identifying information (name, address, phone, etc.) will be disclosed to anyone outside of the DRLC.